PQ2: High-alert medicines and risk minimisation of medication errors

THIS SESSION WILL RUN ONCE ONLY.

ACPE UAN: 0475-0000-19-025-L04-P. A knowledge based activity.

Linked to EAHP Statements

Section 5 – Patient Safety and Quality Assurance: Statements 5.2, 5.4, 5.5, 5.6

Abstract

Approximately 6% of hospitalised patients experience an adverse drug event (ADE) during their hospital stay. An ADE is defined as “any injury resulting from a drug”, including adverse drug reactions (ADRs) and medication errors (MEs). An ADR is a response to a drug which is noxious and unintended and which occurs at doses normally used. An ME is a mistake in the medication-use process caused by omissions or commissions. Around a quarter of medication-related injuries are estimated to be preventable. High-alert medications pose a higher risk for adverse drug events. Errors may or may not be more common with these drugs than with the use of any others; however, the consequences of these errors are more devastating. Anticoagulants and antithrombotics, opioids, insulins and cytotoxic drugs are examples of high-alert medications. How can hospital pharmacists identify unit and specialty specific high-alert medications and try to prevent serious MEs related to these?

An open safety culture, reporting and analysing MEs, structured processes, competence of staff and clinical pharmacy services are essential areas of medication safety and risk minimisation work. Risk minimisation measures aim to optimise the safe and effective use of a medicinal product throughout its life cycle. Planning and implementing risk minimisation measures and assessing their effectiveness are key elements of risk management. While the majority of safety concerns may be adequately addressed by routine risk minimisation measures, additional risk minimisation measures are necessary to manage risks of some medicines, especially post marketing when the medicines are in routine use in practice and taking into account human factors. What is the role of hospital pharmacist in the risk minimisation of these medicines?

Learning objectives

After the seminar, participants should be able to:
• identify unit and specialty specific high-alert medicines;
• describe ways in which risks of high-alert medicines can be minimised;
• understand the role of hospital pharmacists in medication safety and risk minimisation.

Educational need addressed

The seminar shares best practice and supports hospital pharmacists in using research evidence to identify high-alert medicines and to develop risk minimisation services.

Keywords | Adverse drug events, high-alert medicines, medication errors, risk minimisation.